Newborn history taking

Dr Soma Venkatesh, Asst Prof, Pediatrics

Introduction & chief complaint

B/O __________ is a ___ days old male/female baby born in this hospital at term/preterm on
_________ at _____ am/pm by ND/CS. Mother is the informant.

Mother doesn’t give any complaint about the baby

Or
Mother noticed yellowish discoloration of the eyes & skin since _____day of life

(Should know the danger signs of newborn ---bleeding from any site, appearance of
jaundice within 24 hrs of life or deep jaundice, failure to pass meconium within 24 hrs &
urine within 48 hrs, vomiting or diarrhea, poor feeding, lethargy or excessive crying,
excessive frothing or drooling, choking at feeds, breathing difficulty, apneic attacks &/or
cyanosis, sudden rise or fall of temperature, superficial infection like conjunctivitis,
pustules, umbilical discharge or redness suggestive of umbilical sepsis, oral thrush)

History of present illness ( starts from maternal hist)

---------------- is -------- yrs old at present

Married at ---------- yrs of age,
Her blood group is _______
She is not suffering from any medical or surgical illness & not on any medication
(Should mention here if she is on antiepileptics or antitubercular drugs or antithyroid
drugs or thyroxin or antihypertensives etc)
This is her _________-pregnancy
Details about previous pregnancies–abortion(spontaneous/MTP)/stillbirth/livebirth
at which wk of gestation
ND/CS
at home or hospital
Birth wt, any problem at or within 1 month after birth
How old are they now? any problem at present ?

Details about current pregnancy

*Expected date of delivery was on
* Nature of antenatal visits( Regular/irregular- how many visits)
Ideal number of visits & minimum number of visits
*Intake of vitamin tablets(iron & folic acid) given from hosp
Dose of folic acid with & without history of previous child with neural tube
defect, when to start, how long to continue, dose of iron & when to start
*Whether she was on any regular medication during pregnancy
Know some common medications having effect on fetus
*Whether she had fever with rash, swelling in the neck or joint pain during 1st 3 months
*Whether she has any pet at home (above two suggestive of TORCH infection)
 * She is not having any addiction/addicted to ______(smoking-IUGR;alcohol→fetal-
alcohol syndrome)
*Not exposed to any radiation(max radiation permissible throughout pregnancy-500rads)
*History of excessive vomiting(hyperemesis associated with polyhydramnios)
*Whether she has been given 2 doses of tetanus during her pregnancy
*Whether blood sugar was checked during pregnancy, if so was it reported normal h/s/o
*Whether she had any hist of excessive leg swelling,headache,giddiness,blurring of GDM
vision( s/o PIH) , whether BP eas checked during antenatal visits & told to be normal. & PIH
*Which month she was able to perceive fetal movements
Perceived at 20 wks in primi & 16 wks in multi
*Whether she had bleeding PV anytime during pregnancy
*Any history of trauma/surgery
*Whether USG was done, if so when? Was it reported normal?
*How much weight she gained during her pregnancy
(Expected wt gain-10-12 kg; minimum wt gain 7kg)
*Whether she had fever/symptoms suggestive of UTI within 2 wks prior to delivery
(Risk factor for early neonatal sepsis)

Labour & Delivery

*Onset & duration of labour
*Rupture of membrane, color of liquor if noticed or told by doctor
*Method of delivery – If ND ask whether instruments (forceps) were applied
If LSCS , ask what reason the doctor told for CS

Infant’s condition at birth

*Did the baby cry immediately
* If not what kind of resuscitation was needed – Stimulation/oxygen/oxygen+bag&mask
*How many hrs after birth baby started taking direct breast feed?( if the baby had started direct
breast feeding within 2-4 hrs of delivery,then birth asphyxia is unlikely)
*When the baby passed 1st stool & urine?
(delayed passage of mec ie beyond 24 hrs – meconium ileus, cong hypothyroidism,
hirschprung ds, anal stenosis
*Whether the baby is sucking well, how frequently she is feeding, is the baby sleeping
quietly for 1-2 hrs after each feed, is the baby passing urine minimum 6 times/day?
*Problems since delivery
Should know about the common problems & danger signs in newborn
Examination

General examination
*Posture & activity
*Color – Pink- normal
Cyanosis – peripheral/central/localized
Pallor(causes-anemia,shock,edema)
Icterus(by blanching skin over nose,sternum,abdomen,limbs,palm & soles)
Plethora- dark red or magenta color seen in polycythemia
*Edema – localized over dorsum of foot in turners/milroys disease
Generalized in severe anemia, CCF, ARF, 3rd spacing in sepsis & asphyxia
*Cardinal signs –# Heart rate (Normal-120-160; >160-tachycardia)
# Femoral pulsation (weak or absent in coarctation of aorta)
# Capillary refill time(CFT) by pressing on the skin over the
forehead/sternum for 5 sec, colour comes back within 3 sec of
release. CFT>3sec indicates poor perfusion
# Respiration(should be examined in quiet alert or sleeping state).
Normal rate-40 -60/min; RR>60 – tachypnea.
Periodic breathing normal in newborns, specially in preterms
# Temparature – ordinary thermometer kept in axilla for 3 mins
reflects core temperature. Normal 36.5 – 37.5`C
Cold stress – 36 – 36.5`C Hypothermia - <36`C

Regional examination
Head –Head circumference: normal -33-35cm
Microcephaly:3 SD below the mean for GA(causes?)
Hydrocephalus:2SD above the mean for GA(causes?)
Relation with length:[(Length/2)+9.5]±2
Fontanels:Anterior – Normal size at birth 2.5x2.5cm, closes by 9-18 months
Should be examined in quiet/asleep stage & head upright
Posterior fontanel – Closed or admit tip of a finger at birth, closes dy 6-8 wks
(Causes of wide open fontanels with palpable sutural gaps are prematurity,
hypothyroidism, hydrocephalus, Down syndrome, osteogenesis imperfecta)
Craniotabes – softened parietal bone on palpation-a pingpong ball sensation, seen in
prematurity & hydrocephalus
Moulding : Overlapping of cranial bones at suture lines during birth, disappears by7
days
Craniosynostosis :Suture lines appear as prominent bony ridge. Due to early
ossification. May cause skull deformities & raised intracranial tension
Cephalhematoma:Subperiosteal bleeding due to trauma sustained during delivery of
the head, not present at birth but appears within few hrs after birth,
 boundary limited by suture lines, tender & the baby cries on touching,
resoves in 2-12 wks. Complications are anemia & hyperbilirubinemia, may
even need transfusion & phototherapy

Caput succedaneum: Diffuse edema of the scalp tissue, seen at birth, over the
presenting part in vertex presentation, crosses the suture lines, caused by
impaired venous & lymphatic flow due to pressure by the wall of the birth
canal, disappears within 2-3 days, no treatment needed.
Bruit over the AF: Cranial A-V malformation (Vein of galen malformation, presents
with hydrocephalus & CCF)

Face – Eyes - Hypertelorism(distance between inner canthi>40% of distance

between outer canthi or > the length of one eye)
Upslanting(Down syn)/downslanting(Tracher collin syn) eye, epicanthal folds
Subconjunctival hemorrhage-common, resolves on its own
Absent iris(aniridia), associated with wilm’s tumour
Brushfield spots on iris in Down syn
Leucocoria/white pupillary reflex/cats eye reflex in cong cataract etc
Megalocornea ie coreal diameter>10mm suggests cong glaucoma

Nose -Depressed nasal bridge, serosanguinous discharge(snuffles) s/o cong syphilis

Look for choanal atresia by passing a feeding tube(NB are obligate nasal breathers)

Mouth & oral cavity: High arched palate, cleft palate/lip, macroglossia
Epstein pearl-white keratin containing epithelial inclusion cyst over
the hard palate
Wide philtrum , natal teeth, oral thrush
Micrognathia(small mandible) in Pierre Robin & Traecher collin syn
Ear - Abnormal size or shape of ear, low set ear, preauricular tag/sinus
(Horizontal line through inner & outer canthus of eye normally meets the ear at the
junction of upper one third & lower two thirds)
Neck – Excessive skin fold or webbing in Turner syn
Sternomastoid tumour,congenital goiter, branchial cyst, cystic hygroma

Trunk- Trunk limb ratio( short limbs in achondroplasia/ short trunk in MPS)

Breast enlargement on 4th – 7th day (mastitis neonatorum) in both sexes due to
transplacentally passed hormones, subsides spontaneously. Treatment is
masterly inactivity.

Abdominal wall defect : Midline – omphalocele– herniation of abdominal organ

into the base of the cord covered
by peritoneum with no overlying skin
Lateral – gastroschisis

Diastasis recti- Rectus abdominis muscles separated by a gap, common in preterm

 Umbilical cord: Single umbilical artery associated with chromosomal anomaly,
cardiac, renal or intestinal malformation
Cord falls off by 6-8 days, wound heals by 12-15 days
(cause of delayed fall- neutrophil adhesion defects)

Umbilical discharge: pus ±periumbilical erythema→umbilical sepsis

watery(urine)→patent urachus
faeculent→patent vitello intestinal duct

Umbilical granuloma:Persistent excessive granulation tissue at the base of

umbilicus after the cord falls off with seropurulent discharge
Treatment is single application of copper sulphate
crystals or common salt

Umbilical hernia – seen after cord falls off& scar heals. Soft swelling at the
umbilicus covered with skin caused by herniation of abdominal
organs through the umbilical ring, reducible unless obstructed

Distended abdomen-abdominal mass(hydronephrosis/wilms tumor/neuroblastoma,

intestinal obstruction, ascitis(hydrops fetalis)

Scaphoid abdomen- diaphragmatic hernia

Back - Kyphoscoliosis
Midline swelling-meningocele/meningomyelocele
Tuft of hair/sinus/lipomatus swelling in the midline of lower back s/o spina bifida
occulta
Limbs – Syndactyly, polydactyly ie extra digit(preaxial /postaxial)
Erb’s palsy(brachial plexus injury→paucity of movement of the hand) / fractures
Absent radius/ulna(Holt Oram syndrome, TAR syndrome)
Congenital dislocation of hip by Otorloni or Barlow test
Club foot deformity
Arthrogryposis
Edema dorsum of feet in Turner syn/cong lymphedema(milroydisease)
Distance between great toe & 2nd toe (saddle gap in down syndrome)
Hemihypertrophy seen in wilms tumour, neurofibromatosis,A-V malformation
Short limb(achondroplasia)/Amelia/phocomelia

Genitalia: Urethral opening – normal/hypospadius/epispadius

Transitory hydrocele(common)
Ambiguous genitalia
Micropenis - <3cm (Normal penile length 3.6± 0.7 cm)
Phimosis is normal in newborn, little vaginal bleeding at the end of 1st wk is
 common(withdrawal bleeding)

Skin: Milia – 1-2 mm grey/white firm superficial epidermal inclusion cysts seen over face,
esp nose, disappears spontaneously
Mongolian spots – blue/slate gray macules over back or shoulder present at birth,
disappears by 6 months to few yrs.
Erythema toxicum – Benign condition, less common in preterm. Scattered or
clustered yellow white papules surrounded by erythematous macule over the
skin appearing on 2nd to 3rd day, disappearing usually by 24 hrs. Palm & sole
sis spared. Biopsy shows eosinophils in epidermal layers
Salmon patch – Seen in 33-50 % neonates. Small areas of illdefined pink patchy
macules over forehead, eyelids, upperlip or nape of neck. Facial patches
usually disappears.
D/D–Portwine stains→permanent, unilateral, over skin innervated by
ophthal division of Vth cranial N
Strawberry(capillary) hemangioma→raised from surface,
compressible, bright red in colour
Benign pustular melanosis:

SYSTEMIC EXAMINATION

Resp system: Inspection – Resp rate, rhythm, type

Cyanosis(central due to hypoxia)
Grunt(RDS,pneumonia) / stridor(laryngomalacia)
Alae nasi flaring
Shape of chest(normal is rounded with AP diameter=transverse)
Hyperinflated chest+scaphoid
abdomen=diaphragmatic hernia
Subcostal retraction
Palpation – Position of apex beat
Auscultation – Bilateral air entry

* Causes of tachypnea in NB –
Pulmonary(pneumonia,RDS,MAS,pneumothorax,cong diaphragmatic hernia)
Cardiac, Metabolic(acidosis, hypoglycemia),CNS(asphyxia, meningitis),
Hypothermia

* In preterm baby pneumonia/hypoglycemia can manifest with bradypnea or anpea

CVS: Heart rate,rhythm, peripheral pulses, CRT
Cyanosis – Central - Cyanotic congenital heart disease
Persistent pulmonary hypertension
Duct dependent systemic circulation eg. Hypoplastic left heart
Critical aortic stenosis
Severe coarctation of aorta

Peripheral- Normal for few hrs after delivery

Hypothermia, shock, hypoglycemia, polycythemia
Differential- Only lower limbs cyanosed- severe preductal CoA with
PA→Ao shunt through PDA

- Only face & upper limbs cyanosed – TGA + PDA + CoA

Examination of precordium-Apex beat, heart sounds, thrill, murmur,

*Persistent cyanosis,persistent tachycardia,single second sound,persistent heart

murmur & positive hyperoxia test is s/o cyanotic heart disease

*Presence of heart murmur does not necessarily indicate congenital heart ds. A
transient systolic murmur is commonly heard in the pulm area for first 2-3 days.

*CCHD sometimes may not have any murmur eg TGA, Tricuspid or Pulm atresia

ALIMENTERY SYSTEM:

*Abdomen – Inspection : .Shape, cord, umbilicus, abdominal wall defect

- Palpation: *Liver – Normally palpable 2 cm below right costal margin

Normal span-4.5 – 5 cm
Hepatomegaly seen in CCF, septicemia, HIE,
hepatitis(intrauterine infection), glycogen storage disease

*Spleen–Normally not palpable

Splenomegaly seen in hemolytic disease of newborn,
intrauterine infection, sepsis, storage disease
CENTRAL NERVOUS SYSTEM

Features s/o normal CNS

*Active symmetrical movement of all 4 limbs
*Lusty cry, good sucking, swallowing, rooting reflexes
*Clenching of hands which opens periodically
*Palmer grasp & symmetrical

Level of alertness
Head & spine
Cranial nerves
Motor examination – posture
Tone
Abnormal movement ----------Jitteriness
│______Convulsion

NEONATAL REFLEXES

1. Moro reflex –incomplete at 28wks-32 wks, complete by term,

disappears by 3 months,
abnormal if persists beyond 6 months
asymmetric in brachial plx injury,# clavicle, hemiplegia
exaggerated in cerebral irritation
depressed in sick neonate
2. Grasp reflex – palmer & planter, appears at 28 wks, definite at 32 wks
disappears by 3 & 10 months respectively
3. Rooting reflex – appears at 28 wks, disappears by 4 months in awake state & 6
months in sleep state.
4. Sucking reflex – appears at 28 wks, disappearance as rooting
5. Placing reflex – appears at 34 wks, disappears by 6 wks
6. Stepping reflex - same
7. Tonic neck reflex – appears at 34 wks, disappears by 5 months
8. Glabellar tap
9. Crossed extensor reflex – appears at 37 wks, disappears by 1 month
10. Magnet reflex
11. Gallant/trunk incurvation reflex
Other primitive reflexes
1. Landau reflex, appears at 3 months
2. Parachute reflex develops at 6-9 months, present throughout the life